Provider Demographics
NPI:1659554517
Name:WAYZATA DENTAL, LTD.
Entity Type:Organization
Organization Name:WAYZATA DENTAL, LTD.
Other - Org Name:WAYZATA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-473-4900
Mailing Address - Street 1:250 CENTRAL AVE N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1206
Mailing Address - Country:US
Mailing Address - Phone:952-473-4900
Mailing Address - Fax:952-473-4672
Practice Address - Street 1:250 CENTRAL AVE N
Practice Address - Street 2:SUITE 202
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1206
Practice Address - Country:US
Practice Address - Phone:952-473-4900
Practice Address - Fax:952-473-4672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty